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Utilization Management

All criteria utilized in utilization management are available upon request. The request can be made independent of a specific case. Reviewers and Physician Advisors are also available to discuss  any and all utilization management decisions, questions  or issues. To request specific utilization management criteria or to speak with a MSFC Reviewer or Physician Advisor please contact us during our normal business hours, 8:30 AM to 5:00 PM Monday through Friday, at 800-907-1722 or 410-933-2200. The fax# is 410-933-2274. Messages received outside of normal business hours will be addressed the following business day.

Pre-Authorization

MedStar Family Choice follows a basic pre-authorization process: A member's physician forwards clinical information and requests for services to MedStar Family Choice by phone, fax or infrequently by mail. You may contact a case manager on business days from 8:30am-5pm at 410-933-2200 or 1-800-905-1722. Our fax number is 410-933-2274 and faxes are received 24 hours/day, 7 days /week. Faxes and voice messages received after hours will be addressed the next business day. The after hours voice mail message includes name and telephone number to contact for after hours needs. The message also contains telephone# for MSFC representative to be contacted for urgent pharmacy issues.

All appropriate ICD-9s/CPT/HCPCS, along with supporting clinical information must be included in requests for pre-authorization. Requests for authorization can be included on the Maryland Uniform Consultation Referral Form* with clinical information attached. Our experienced clinical staff reviews all requests. MedStar Family Choice pre-authorization decisions are based on the following criteria:

  • MedStar Family Choice Protocols
  • MSFC Pharmacy Policies and Procedures
  • InterQual
  • Medicare and Medicaid Guidelines
  • COMAR
  • MSFC MCO benefit coverage
  • MSFC Provider Manual
  • MSFC Member Handbook
  • FDA Approval
  • Maryland Medicaid DMS/DME Program Approved List of Items
  • Availability of services within the MSFC network
  • MSFC Continuity of Care Policy
  • Pain Management Contracts

MSFC reserves the right to direct services to participating providers and facilities. Services outside the network are available only when they are not available within the network, for continuity reasons.

MedStar Family Choice's utilization management decision making is based on the medical necessity of the service and the existence of MCO enrollment and coverage.

MedStar Family Choice requires up to two business days to process a complete, non-urgent authorization request. Requests are considered complete when all necessary clinical information is received from the requesting provider. The final decision cannot take longer than seven days, whether or not all clinical information has been received. If the service requested is denied the provider may contact our Care Management Department to discuss the decision with the appropriate physician advisor.

A limited number of services require authorization from MedStar Family Choice Care Management before the patient receives care. The list is included in the MSFC Provider Manual.

Retrospective requests are reviewed against the above specified criteria and are not guaranteed for approval. Retrospective services that could have been provided within the network are not likely to be retrospectively approved unless upon review the care was urgent/emergent, a COMAR defined self referral service, or a continuity of care issue.

DME and services that are carved out to the State of Maryland Medicaid, which include, but are not limited to, pediatric outpatient rehabilitation services and mental health care are subject to administrative denial since they are not the liability of the MCO.

Pharmacy

MSFC pays for a wide variety of medications, as outlined in our formulary. If a physician feels it medically necessary to prescribe a medication not on the formulary, the physician may submit this request to MSFC. Such a request must include clinical documentation that supports the medical need for that specific medication. All non-formulary requests are reviewed by a physician advisor. MSFC does not guarantee coverage of medications, which are outside the guidelines set forth in the manual. Physicians may call MedStar Family Choice at 410-933-2200, or fax requests to 410-933-2274.

Requests for Synagis (palivizumab) require a completed Statement of Medical Necessity form and authorization is based on criteria set forth by the American Academy of Pediatrics Policy Statement.

Medications covered by the Department of Health and Mental Hygiene, such as HIV/AIDS medications and mental health drugs are not covered by the MSFC MCO. These requests are subject to administrative denial since they are not the liability of the MCO.

Concurrent Review

MSFC utilizes the following criteria to make concurrent review decisions:

  • InterQual
  • Medicare and Medicaid Guidelines
  • COMAR
  • MSFC benefit coverage
  • Availability of services within the MSFC network

MSFC reviews clinical documentation for timeliness of care and appropriate level of care. Clinical denial determinations may be issued by our physician advisors when a delay in care or delay in discharge planning creates an inpatient day that could have been avoided if service had been provided timely.

While MSFC care managers are available to assist with discharge planning, it is the responsibility of the inpatient facility to provide timely and appropriate discharge planning. Inpatient days that do not meet medical necessity as outlined in above criteria are the responsibility of the inpatient facility.

Services that are carved out to the State of Maryland Medicaid, which include but are not limited to mental health care, are subject to administrative denial since they are not the liability of the MCO.

MSFC follows Maryland Medicaid Fee for Service guidelines when conducting inpatient reviews where a guardianship hearing is necessary to determine post acute disposition. In the absence of medical necessity, MSFC approves the first 2 days following the decision that guardianship is needed.

Emergency Care

In accordance with the Emergency Medical Treatment & Labor Act (EMTALA), MSFC will pay claims for all medical screening examinations (MSE) when the request is made for examination or treatment for an emergency medical condition (EMC), including active labor. MSFC does not consider a nurse exam or triage information as evidence of a medical screening exam.

In accordance with the Balanced Budget Act of 1997, MSFC pays for emergency services using a prudent layperson standard. An "emergency medical condition" is defined as:

A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonable expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

MSFC requires and fully reviews emergency department clinical documentation for evidence of a medical screening exam, prudent layperson guidelines, as well as evaluation of assigned treatment levels based on HSCRC guidelines for reasonable clinical care time. Services that are carved out to the State of Maryland Medicaid which include but are not limited to mental health care, are subject to administrative denied since they are not the liability of the MCO. MSFC does not specifically reward practitioners or other individuals for issuing denials of coverage of care. In addition, there are no financial incentives for UM decision makers that would encourage decisions that result in underutilization. Providers may request the UM criteria utilized for a specific case by calling the MSFC Care Management Department @ 1-800-905-1722 or 410-933-2200. We are available Monday-Friday 8:30am-5pm.

Substance Abuse

Admissions for alcohol or other substance abuse issues, even if admitted to a medical bed, are referred to Value Options, Substance Abuse [VO/SA] for authorization and claims payment. ASAM utilization management criteria are used per plan benefit. 

To request inpatient authorizations for substance abuse admissions to medical beds, the hospital utilization reviewer may contact VO/SA directly by calling:1-866-702-9023, extension 292797 or extension 292592. The Utilization reviewer may also contact VO @1-800-496-5849 to request authorizations. Providers may also access the ValueOptions website for additional information.

MSFC Case Managers/utilization review staff are also available to assist the hospital utilization review staff with 3 way calls to facilitate this process.

VO Substance Abuse address for claims submission:
Value Options
PO Box 1347
Latham, NY 12110

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This page was last updated on 12/02/14

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